Enrollment Application -Back to the Basics T

Enrollment Application

Complete this form to start the enrollment process.

Please tell us your first and last name.

Email (Please enter an email you check often. We communicate by email often.)

Address

Phone Number

What is your child's name and date of birth?

What school does your child attend?

Is your child struggling in reading or math?

Yes

Does your child have any learning challenges such as a disability, IEP, or more than two grade levels behind?

Yes

Does your child wear glasses?

Yes

Has your child reported seeing letters move, get blurry or change while reading?

Yes

Does your child wear hearing aids or have trouble hearing?

Yes

Can your child talk and be understood by people outside of family?

Yes

Can your child follow multi-step directions?

Yes

Can your child remember what they've learned?

Yes

Is your child fully potty trained?

Yes

Can your child zip or button their clothes without help?

Yes

Are your child's physical abilities limited in any way?

Yes

Can they walk or run without assistance?

Yes

Does your child have a hard time staying focused or following directions?

Yes

Has your child had academic or learning concerns in previous years?

Yes

Can your child make friends easily?

Yes

What sparks your child's interest?

What causes your child to become frustrated?

What subject is your child good at?

What area do you believe your child needs the most improvement?

Is there anything else we should know about your child?

What do you expect your child to gain from our program?

NOTE: Back to the Basics Tutoring LLC does not guarantee any particular results; however, we will work hard to help your child. I understand this form is used to determine if my child needs can be met. This form is for our informational use only.

How did you hear about us?

Referral

Google, Facebook, Instagram, Tiktok or other internet sources

Employee

Does your child take any medication that may affect their learning or behavior?

Is your child allergic to any medication, food, etc.? What is the severity of their allergy? What should be done in case of a reaction? (EpiPen, inhaler, etc.)

Does your child suffer from any pre-existing medical conditions (seizures, diabetes, mental health issues, eating disorders, etc.)? What are the warning signs that we should be aware of, and what should be done in case of emergency?

Does your child take any prescription medications? If so, please list prescriptions and dosage information. (In case of an emergency, we can give the correct information to authorities.)

Is there any other information about your child's health or medical history that we should know prior to the start of the program?

Name of 2 Emergency Contacts (Include their name, address, relationship to the child and phone number)

What is the contact information for your child's doctor? ( Include name, address, phone number )

I understand that I am to get my child to class on time to ensure they are able to benefit from their entire session. If I will be more than 6 minutes late, I understand I must call, text or chat on the website.

I understand that it is required to have my child practice skills learned in tutoring using BT2B online resources.

I understand that I am to help my child keep all books, materials, electronics or resources in good condition. I understand that if it is not, I may be charges for replacements. i

I understand that if any of my contact information changes, I am to notify B2TB immediately.

I understand that I am responsible for transportation to and from scheduled activities.

I understand that I am to ensure my child has all medications needed to participate in scheduled activities and no person at or affiliated with B2TB can administer medication.

Release of Information/Pictures/Videos

I grant permission to Back to the Basics Tutoring LLC and its agents, volunteers, and employees the irrevocable and unrestricted right to create or reproduce the photographs, audio and/or video images taken of my child, or members of my family, with or without their name or any other identifying information, for the purpose of publication, promotion, illustration, advertising, in any manner or in any medium. I hereby release Back to the Basics Tutoring LLC and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation regarding said images, videos, interviews, statements, and lectures.

I have received, read, and understand the Social Media Release.

I understand that this tutoring program is Christian-based and I was made aware by Back to the Basics Tutoring LLC of such. I also understand that my child may be receiving bible lessons as part of the tutoring program. I am aware that the main focus of the bible lessons is Jesus Christ and God and his dying on the cross for our sins. I am also aware that my child may be given and explained Christian principles. I understand that I or my child do not have to have the same faith or belief to receive the tutoring services; however, I understand that if the lessons are given to each child, it will be done as a scheduled activity of the program.

I have received, read and understand the Notification of Bible Teaching.

Acknowledgement of Handbook

This is to acknowledge that you have received, read, and understand the family handbook. The handbook is in your member portal under "Tutoring Handbook". Once you enroll, you will have access to your member portal.

I acknowledge that I've read and understand the handbook.

I understand and agree to the terms & conditions

I understand that I will have to give a 48 hour notice if my child will not attend class.

I grant permission for Back to the Basics Tutoring LLC, including but not limited to its volunteers, affiliates, members, or associates to provide or arrange for medical treatment and/or transportation to an evacuation site and/or medical facility for my child, identified above, during an emergency or disaster. I also grant permission for my child to be released to any of the emergency contacts I have designated above if I am unable to pick them up in an emergency or at any other time. I agree to not hold Back to the Basics Tutoring LLC, its affiliates, partners, sponsors, volunteers, directors, associates, or members liable for any harm, medical needs, food allergies, or illness that occurs while in or outside of the program.

I have received, read and understand the Medical Arrangement.

I agree to be contacted by Back to the Basics Tutoring via texts, calls and emails. To Opt-out reply 'stop' at anytime or click the unsubcribe link in the emails. Message and data rates may apply.

Your Signature